[Giant mucocele of appendix. Case report]

Appendiceal mucocele is an uncommon disorder caused by accumulation of mucus within the appendiceal lumen. Mucoceles represent a heterogeneous group comprising various histopathologic lesions including mucosal hyperplasia, cystoadenomas, and cystoadenocarcinomas and prognosis is related to these subtypes. The most common symptom is pain or a palpable mass in the right lower quadrant on physical examination. The preoperative diagnosis is performed with abdominal U.S. and confirmed with CT scan; typical CT scan image is a capsulated cystic mass with calcification of the wall while U.S. pattern shows cystic lesion with the onion skin sign considered a specific sonographic marker for appendiceal mucocele. In conclusion a cystic mass sonographically detected with onion skin sign, in the presence of normal female reproductive organs, suggest the diagnosis of appendiceal mucocele.

Combined endoscopic treatment for cholelithiasis associated with choledocholithiasis

BACKGROUND

The advent of endoscopic techniques changed surgery in many ways. For the management of cholelithiasis, laparoscopic cholecystectomy (LC) is the treatment of choice. This has created a dilemma in the management of choledocholithiasis. Today a number of option exist, including endoscopic sphinterotomy (ES) before LC in patients with suspected common bile duct (CBD) stones, laparoscopic bile duct exploration, open CBD exploration, and postoperative endoscopic retrograde cholangiopancreatography (ERCP). Also, the alternative technique of peroperative ES is emerging.

METHODS

We report our experience of routine intraoperative cholangiography followed either by peroperative ERCP in one step or by transcystic drain and postoperative ERCP. In our technique, to facilitate Vater papilla cannulation we inserted a 450-cm transcystic guidewire that was caught by a duodenoscope. Papillotome was then inserted over the guidewire to ensure cannulation of the CBD.

RESULTS

Twenty-eight patients were treated successfully in one step and 24 in two steps. The mean operative time was 181 +/- 41 min for patients treated in one step and 131 +/- 30 min for patients treated in two steps. The mean hospital stay was 4.8 +/- 3.3 days for patients treated in one step and 9.6 +/- 4.0 days for patients treated in two steps. Five patients (18%) with positive intraoperative cholangiography for stones for whom peroperative ERCP was not available showed a normal postoperative transcystic cholangiogram and therefore ERCP was canceled. Fourteen of 25 patients treated in one step and none of 17 treated in two steps had raised serum amylase, which resolved spontaneously with no symptoms. No patient developed postoperative pancreatitis. Three (10%) ERCP complications were observed, consisting of mild bleeding of the papilla. All cases were managed by endoscopic adrenaline injection. There was no mortality.

CONCLUSION

We believe peroperative ERCP with the technique described should be considered as the treatment of choice for choledocholithiasis associated with cholelithiasis. When single-stage treatment is not possible, a two-step rendezvous technique should be preferred.

New technique for optical control of the first trocar insertion

BACKGROUND

In laparoscopic surgery serious complications caused by the blind insertion of the first trocar have been reported even after the pneumoperitoneum is established by means of a Veress needle. As a consequence, some techniques to safely insert the first port have been developed. Many surgeons advocate a minilaparotomy to position the first port. However, especially in obese patients, the dissection to insert the Hasson's trocar may be difficult and time consuming. As an alternative, optical disposable trocars have been studied and produced to be safely positioned under direct visualization.

METHODS

A new technique to insert, under adequate optical control, a non disposable standard port is described. Personal experience in 126 consecutive patients is reviewed. Data were recorded prospectically and insertion time was recorded in every case.

RESULTS

Medium time of trocar insertion was 55 sec (range 30-160 sec). Identification of distinct layers of the abdominal wall was always possible. There were no complications related to the insertion of the first reusable cannula under visual control.

CONCLUSIONS

This technique may be considered a safe, simple and cost effective method to insert the first trocar.

Laparoscopic-assisted Hartmann's reversal with the Dexterity Pneumo Sleeve

Several laparoscopic techniques of Hartmann reversal have been published. An alternative laparoscopic-assisted procedure, essentially aseptic, which uses the minilaparotomy for colostomy mobilization to apply the Dexterity Pneumo Sleeve device is described. This technique combines the advantages of the minimally-invasive approach with the direct access of the surgeon's hand to the patient's abdomen.

[Colorectal neoplasms in young patients]

The prognostic factors regarding colon-rectal cancers in the under-40s are examined. A personal series of 15 cases shows that the incidence of tumour recurrence is higher and the disease-free interval shorter than in patients not selected for age and that 5-year survival is much less. These results permit the hypothesis of greater aggressiveness in colorectal cancers in the young, something that justifies the severer prognosis by comparison with the elderly population.

[Importance of preoperative monitoring in a case of hypochloric and hypokalemic dehydration subsequent to upper intestinal occlusion, caused by biliary ileus]

A personally observed case of biliary ileus triggers this description of its clinical features, blood chemical and diagnostic aspects and surgical treatment. Emphasis is placed on the importance of the preoperative rehydration and restoration of the electrolyte balance in patients with upper intestinal occlusion which reduces the risk involved in subsequent surgery.

[Current approach to the treatment of acute pancreatitis with reference to the use of somatostatin]

A series of 172 cases of acute pancreatitis encountered between 1-1-79 and 30-4-88, including 57 treated with somatostatin is presented. A comparison between the latter and the other cases treated with a variety of drugs (aprotinin, cimetidine, ranitidine) led to the following conclusions: 1) somatostatin significantly improves the clinical course of acute oedematous pancreatitis with circumscribed necrosis; 2) it makes no difference to the development of cases with diffuse necrosis and haemorrhage.